Massive Transfusion Protocol

Reviewed and revised 10 March 2014

OVERVIEW

Massive transfusion is defined as

• replacement of >1 blood volume in 24 hours, or
• >50% of blood volume in 4 hours (adult blood volume is approximately 70 mL/kg), or
• in children:  transfusion of >40 mL/kg (blood volume in children over 1 month old is approximately 80 mL/kg)

A Massive Transfusion Protocol should be used in critically bleeding patients anticipated to require massive transfusion

GOALS IN MANAGEMENT OF MASSIVE TRANSFUSION

• early recognition of blood loss
• maintenance of tissue perfusion and oxygenation by restoration of blood volume and haemoglobin (Hb)
• arrest of bleeding in combination with use of early surgical or radiological intervention, and
• judicious use of blood component therapy to correct coagulopathy

THERAPY INDICATIONS IN MASSIVE TRANSFUSION

• Check these parameters early and frequently (e.g. every 30-60 minutes while massive transfusion is ongoing)

Parameters	Values to aim for
Temperature	>35 °C
Acid-base status	pH >7.2, base excess <–6, lactate <4 mmol/L
Ionised calcium (Ca)	>1.1 mmol/L
Haemoglobin (Hb)	This should not be used alone as transfusion trigger; and, should be interpreted in context with haemodynamic status, organ & tissue perfusion.
Platelet (Plt)	≥ 50 x 10^9 /L (>100 x 10^9 if head injury/ intracranial haemorrhage)
PT/APTT	≤ 1.5x of normal
Fibrinogen	≥ 1.0 g/L

MASSIVE TRANSFUSION PROTOCOL TEMPLATE

• See Massive transfusion protocol template

PROBLEMS WITH MASSIVE TRANSFUSION

Risks and complications of large volume resuscitation with blood products

• volume overload (careful monitoring of filling pressures, response to volume, diuresis etc)
• over-transfusion (monitor Hb regularly, titrate according to needs)
• hypothermia (monitor temp, use fluid warmers and other measures to reduce heat loss)
• dilutional coagulopathy of clotting factors and platelets (regular and early monitoring of coagulation, involvement of haematology for replacement therapy )
• Transfusion related acute lung injury (consider use of filters, leukodepletion)
• excessive citrate causing metabolic alkalosis and hypocalcaemia (monitor pH and ionised calcium, replace calcium as necessary)
• hyperkalaemia (use of younger blood, monitor regularly, may require specific therapy)
• disease transmission (use of products only on a needed basis only, standard blood banking precautions etc)

If uncross-matched / O neg blood

• Haemolytic disease of newborn if RhD mismatch
• Difficulty with cross-matching future blood product
• Difficulty with matching solid organs

Logistical issues

• distractions resulting in not controlling source of haemorrhage, and
• risks of hurried cross-checking and incompatibility (allocation of sufficient resources and personnel, standard programs in place to facilitate process and anticipate needs)
• other problems including loss of identity, crossmatching issues, loss of baseline haematological information etc)

Usual transfusion reactions and problems

• TRALI / TACO
• Acute / delayed haemolytic transfusion reaction
• Non-febrile haemolytic transfusion reaction
• Bacterial / viral infection
• Anaphylaxis if IgA deficient
• GVHD
• Storage lesion effects

References and Links

CCC Transfusion Series
Blood Products	Cryoprecipitate, Fresh Frozen Plasma (FFP), Platelets, Red Cells (RBCs) Concentrates: Prothrombinex, Factor VIIa, Fibrinogen Concentrate
Reversal	Rivaroxaban / Apixaban / Enoxaparin: Andexanet Alfa, Rivaroxaban and Bleeding Dabigatran: Idarucuzimab, Dabigatran and bleeding Heparin: Protamine Warfarin: Vitamin K / FFP / PTx, Warfarin Reversal, Warfarin Toxicity
Testing	Coagulation Studies, TEG / ROTEM (Thromboelastography), Platelet function assays
General Topics	Acute Coagulopathy of Trauma, Blood Bank, Blood conservation strategies, Blood Product Compatibilities, Blood transfusion risks, Disseminated Intravascular Coagulation, Massive blood loss, Massive transfusion protocol (MTP), Modifications to blood components,Procedures and Coagulopathy, Storage Lesions, TRALI, Transfusion Literature Summaries, Transfusion Reactions

References

• National Blood Authority. Patient Blood Management Guidelines: Module 1 – Critical Bleeding/Massive Transfusion.[cited 2011 Jun 30]. Available from: http://www.nba.gov.au.

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